Time Of Catheter Placement Research Articles

Initial experience with percutaneous coronary sinus catheter placement in minimally invasive cardiac surgery in an academic center.

BackgroundPlacement of a percutaneous coronary sinus catheter (CSC) by an anesthesiologist for retrograde cardioplegia in minimally invasive cardiac surgery is relatively safe in experienced hands. However, the popularity of its placement remains limited to a small number of centers due to its perceived complexity and potential complications.MethodsWe retrospectively reviewed all cardiac cases performed by one surgeon between December 2009 and April 2012. The reviewed cases were divided into two groups: cardiac cases with percutaneous CSC placement (CSC group) and cardiac cases without placement (control group). Anesthesia preparation time (APT) was then compared between the CSC group and control group. In the CSC group, cases were further divided into two groups. One group contained cases with an APT of less than 90 min (success group) and the other contained cases with an APT greater than or equal to 90 min or cases with CSC placement failure (delay/failure group). Patients’ characteristics, type of surgery, and transesophageal echocardiography (TEE) findings were compared between the two groups (success group vs. delay/failure group) to identify variables associated with prolongation of the APT or CSC placement failure.ResultsPercutaneous CSC placement was required in 83 cases (CSC group). The catheter was successfully placed in 74 of those cases. We experienced one complication, coronary sinus injury after multiple attempts at placing the catheter. The mean APT was 102 ± 31 min in the CSC group (n = 81) and 42 ± 15 min in the control group (n = 285). We could not identify any variables associated with prolongation of the APT or catheter placement failure.ConclusionsThe success rate of the placement was 89.1 % in our academic center. On average, placing the CSC added approximately one additional hour to the APT. This time is not an accurate representation of true catheter placement time, as it included time for preparation of the CSC, TEE, and fluoroscopy. We experienced one documented complication (coronary sinus injury), which was immediately diagnosed by TEE and fluoroscopy in the operating room. No variables associated with prolongation of APT or CSC placement failure were identified.Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-016-0203-4) contains supplementary material, which is available to authorized users.

Tunneled Pleural Catheter Placement with and without Talc Poudrage for Treatment of Pleural Effusions Due to Congestive Heart Failure.

There is a paucity of evidence regarding the role of tunneled pleural catheters in pleural effusions caused by congestive heart failure that is refractory to medical management. The aim of this study was to assess the feasibility of tunneled pleural catheter drainage for treatment of refractory pleural effusions associated with congestive heart failure, either when used alone or with concomitant talc pleurodesis performed during thoracoscopy. This was a retrospective cohort study. We identified patients with congestive heart failure and recurrent symptomatic pleural effusions who were treated between 2005 and 2015 by placement of a tunneled pleural catheter. Patients underwent either thoracoscopy followed by talc poudrage and pleural catheter placement (group 1) or catheter insertion alone (group 2). Forthy-three catheters were inserted in 36 patients, with 15 placed in group 1 and 28 in group 2. Successful pleurodesis was seen in 80% in group 1 and 25% in group 2. The median time of catheter placement was 11.5 days in group 1 and 66 days in group 2. There was a significant decrease in hospital admissions and pleural interventions after catheter placement compared with before insertion (P < 0.05). This single-center, retrospective study demonstrated the feasibility of catheter placement used alone or with talc poudrage for the treatment of refractory pleural effusions associated with congestive heart failure. The addition of talc poudrage might increase the pleurodesis rate and reduce the days to catheter removal in highly selected patients. Prospective studies on a larger number of patients are warranted to verify the safety and efficacy of this intervention.

A comparison of ultrasound alone vs ultrasound with nerve stimulation guidance for continuous femoral nerve block in patients undergoing total knee arthroplasty

Study ObjectiveTo compare analgesic efficacy of ultrasound (US) guidance alone and US guidance combined with nerve stimulation (NS) for continuous femoral nerve block (CFNB) in patients undergoing total knee arthroplasty (TKA). DesignProspective, randomized double-blind trial. SettingPostanesthesia care unit and general ward. PatientsFifty American Society of Anesthesiologist physical status I to II patients undergoing TKA under spinal anesthesia. InterventionsIn group A (n = 25), an 18-gauge Tuohy needle was directed at the lower mid-part of the femoral nerve, and a nonstimulating catheter was inserted through the needle under US guidance. In group B (n = 25), an 18-gauge Tuohy needle and stimulating catheter were directed to the lower part of femoral nerve under US guidance, and quadriceps muscle contraction was checked using NS. All patients received a 20-mL loading dose of 0.2% ropivacaine, a continuous infusion of 4 mL/h, and a 4-mL bolus of 0.2% ropivacaine with a lockout time of 60 minutes for patient-controlled analgesia. MeasurementsThe primary outcome was resting and exercising pain quality assessed by numeric rating scale. Other outcomes included procedure time for correct catheter placement, block failure rate, patient satisfaction for postoperative pain control, total dose of local anesthetic, additional opioid requirement, and adverse effects postoperatively. Main ResultsThere were no significant differences between groups in resting and exercising numeric rating scale. Procedure times were longer in group B than group A (P < .05). There were no significant differences between groups in block failure rate or other outcomes. ConclusionsUS-guided CFNB was associated with similar analgesic efficacy and block failure rate and reduced procedure time compared to US with NS guidance for CFNB in patients undergoing TKA.

The Decision to Incision Curriculum

PURPOSE: To evaluate the effectiveness of a preoperative skills curriculum, and to assess competence in associated level 1 Milestones. BACKGROUND: With implementation of the Milestones, medical educators must ensure that incoming interns have met various level 1 Milestones, including those related to preoperative skills for which formal education is lacking. METHODS: Thirteen fourth-year medical students completed the Decision to Incision curriculum which taught preoperative consent, patient positioning, Foley catheter placement, surgical scrub, and preoperative time out. Knowledge, skills, and competency were assessed using checklists before and after the educational intervention. Performance was measured using a 5-point Likert scale, and competency was assessed as present or absent. Change in performance was analyzed using χ2 and t tests. RESULTS: Overall performance significantly improved for 3 of 5 skills with scores improving from 2.69 to 4.33 (P<.001) for consent, 2.08–4.3 (P<.001) for positioning, and 2.23–3.69 (P<.001) for time out. The percentage meeting Milestone competency significantly improved from 30.8% to 84.6% (P=.005) for consent, 0–100% (P<.001) for positioning, 69.2–100% (P=.03) for scrub, and 15.4–100% (P<.001) for time out. Overall, competence was achieved in 93.8% (61/65) of skills assessments. DISCUSSION: The Decision to Incision Curriculum significantly improves preoperative skills, particularly skills students are unlikely to perform during medical school but may perform on day 1 of residency. This curriculum also facilitates achievement and documentation of competence in multiple Milestones.

Flebitis asociada con accesos venosos periféricos en niños: revisión sistemática de la literatura

Objective: To carry out a systematic review of the literature on the occurrence of phlebitis related to short peripheral venous catheters in children. Methodology: We searched PubMed, Scopus and Scielo databases using venous catheter, infection, phlebitis and synonyms as free terms, no language restriction, in the last 10 years (since the CDC made its recommendations). Results: From an initial total of 1486 references, 9 measured the frequency of phlebitis and its relationship to the time of catheter placement. These studies were performed on heterogeneous

Gd-EOB-DTPA-enhanced MR guidance in thermal ablation of liver malignancies.

ObjectiveTo evaluate the potency of Gd-EOB-DTPA to support hepatic catheter placement in laser ablation procedures by quantifying time-dependent delineation effects for instrumentation and target tumor within liver parenchyma. Monitoring potential influence on online MR thermometry during the ablation procedure is a secondary aim.Materials and Methods30 cases of MR-guided laser ablation were performed after i.v. bolus injection of gadoxetic acid (0.025 mmol/Kg Gd-EOB-DTPA; Bayer Healthcare, Berlin, Germany). T1-weighted GRE sequences were used for applicator guidance (FLASH 3D) in the catheter placement phase and for therapy monitoring (FLASH 2D) in the therapy phase. SNR and consecutive CNR values were measured for elements of interest plotted over time both for catheter placement and therapy phase and compared with a non-contrast control group of 19 earlier cases. Statistical analysis was realized using the paired Wilcoxon test.ResultsSustainable signal elevation of liver parenchyma in the contrast-enhanced group was sufficient to silhouette both target tumor and applicator against the liver. Differences in time dependent CNR alteration were highly significant between contrast-enhanced and non-contrast interventions for parenchyma and target on the one hand (p = 0.020) and parenchyma and instrument on the other hand (p = 0.002). Effects lasted for the whole procedure (monitoring up to 60 min) and were specific for the contrast-enhanced group. Contrasting maxima were seen after median 30 (applicator) and 38 (tumor) minutes, in the potential core time of a multineedle procedure. Contrast influence on T1 thermometry for real-time monitoring of thermal impact was not significant (p = 0.068–0.715).ConclusionResults strongly support anticipated promotive effects of Gd-EOB-DTPA for MR-guided percutaneous liver interventions by proving and quantifying the delineating effects for therapy-relevant elements in the procedure. Time benefit, cost effectiveness and oncologic outcome of the described beneficiary effects will have to be part of further investigations.

Correlation of gross urine color with diagnostic findings in male cats with naturally occurring urethral obstruction.

Seventy-five male cats with urethral obstruction were prospectively enrolled to evaluate gross urine color at urinary catheter placement for correlation with diagnostic findings. Cats with darker red urine were more likely to be azotemic (serum creatinine concentration >2.0 mg/dl [177 µmol/l]), and urine color correlated well with serum creatinine and serum potassium concentrations. Darker urine color was negatively correlated with urine specific gravity. Urine color was not associated with the presence or absence of lower urinary tract stones on radiographs or ultrasound. Cats with darker red urine at the time of urinary catheter placement are likely to have more significant metabolic derangements and may require more aggressive supportive care.

Clinical application of homemade percutaneous abdominal paracentesis needle in ventriculo-peritoneal shunt

To explore the manipulation and safety of homemade percutaneous abdominal paracentesis needle for abdominal paracentesis in ventriculo-peritoneal shunt. A total of 36 hydrocephalus patients were enrolled in the study. The whole process of abdominal paracentesis and catheter placement was observed, and the time, success rate and safety were evaluated. As results, the success rate of catheter placement was 100%; the average time of paracentesis and catheter placement was 5 min; neither intra-abdominal bleeding nor organ injury was found. The results prompt the homemade percutaneous abdominal paracentesis needle for abdominal paracentesis in ventriculo-peritoneal shunt is safe, minimally invasive, easy to perform with a high success rate and a small surgical scar. doi: 10.3969/j.issn.1672-6731.2014.06.015

SU‐C‐16A‐01: In Vivo Source Position Verification in High Dose Rate (HDR) Prostate Brachytherapy Using a Flat Panel Imager: Initial Clinical Experience

Purpose:We report our initial clinical experience with a novel position‐sensitive source‐tracking system based on a flat panel imager. The system has been trialled with 4 prostate HDR brachytherapy patients (8 treatment fractions) in this initial study.Methods:The flat panel imaging system was mounted under a customised carbon fibre couch top assembly (Figure 1). Three gold fiducial markers were implanted into the prostate of each patient at the time of catheter placement. X‐ray dwell position markers were inserted into three catheters and a radiograph acquired to locate the implant relative to the imaging device. During treatment, as the HDR source dwells were delivered, images were acquired and processed to determine the position of the source in the patient. Source positions measured by the imaging device were compared to the treatment plan for verification of treatment delivery.Results:Measured dwell positions provided verification of relative dwell spacing within and between catheters, in the coronal plane. Measurements were typically within 2.0mm (0.2mm – 3.3mm, s.d. 0.8mm) of the planned positions over 60 dwells (Figure 2). Discrimination between larger dwell intervals and catheter differentiation were clear. This confirms important delivery attributes such as correct transfer tube connection, source step size, relative catheter positions and therefore overall correct plan selection and delivery. The fiducial markers, visible on the radiograph, provided verification of treatment delivery to the correct anatomical location. The absolute position of the dwells was determined by comparing the measured dwell positions with the x‐ray markers from the radiograph, validating the programmed treatment indexer length. The total impact on procedure time was less than 5 minutes.Conclusion:The novel, noninvasive HDR brachytherapy treatment verification system was used clinically with minor impact on workflow. The system allows verification of correct treatment delivery, free of most potential human related errors identified in ICRP 97.This research is supported by funding from the Australian Government Department of Health through Cancer Australia grant no. 616614.

Catheter Insertion for Intravenous (IV) Contrast Infusion in Multidetector-Row Computed Tomography (MDCT)

This study evaluated the effect of intravenous (IV) catheter gauge size on catheter placement, contrast infusion, and image quality for patients undergoing IV contrast-enhanced multidetector computed tomography (MDCT). One thousand consecutive adult outpatients undergoing IV contrast-enhanced MDCT and 10 IV insertion CT nurses were observed from IV catheter selection through IV removal. Patients' demographics, number of sticks required, catheter gauge during each attempt, time for catheter placement, IV nurses' assessment of vein quality and contrast infusion parameters were recorded. Scan quality was assessed subjectively. Subjects included 547 men and 453 women, with a mean age 59.2 years (range, 19-92 years). Median number of catheter attempts was 1 per patient (range, 1-9). Catheters were successfully placed in 98%. First and final catheters were most commonly 20 gauge (59% and 56%, respectively), followed by 22 gauge (34% for both), 18 gauge (6% for both), and 24 gauge (2% and 3%, respectively). Mean infusion rate correlated with catheter gauge: 5.3 mL/s for 18 gauge; 3.5 mL/s for 20 gauge; 2.3 mL/s for 22 gauge; and 1.7 mL/s for 24 gauge (P < 0.0001). Target infusion rate of ≥ 3 mL/s was related to catheter gauge (100% of 18 gauge, 71% of 20 gauge, 11% of 22 gauge, and 0% of 24 gauge; P < 0.0001). Nine hundred sixty-eight subjects underwent imaging. Most of the CT examinations (935/968 [97%]) were of acceptable quality. Experienced IV starters usually achieve IV access in one attempt by tailoring IV catheter gauge to vein quality; however, target infusion rates are not likely to be achieved with 22- and 24-gauge catheters, used in nearly 1/3 of the patients in this study.

Laparoscopic techniques enable peritoneal dialysis in the difficult abdomen.

Background and Objectives:Continuous ambulatory peritoneal dialysis has become an increasingly popular modality of renal replacement therapy. Laparoscopic placement of peritoneal dialysis catheters may help overcome previous barriers to peritoneal dialysis, such as previous abdominal surgical procedures or the presence of hernias, without incurring substantially greater risks.Methods:We performed a retrospective review of 120 consecutive patients who underwent attempted laparoscopic peritoneal dialysis catheter placement between July 2009 and June 2014 by a single surgeon. Patient and catheter characteristics and outcomes were compared between patients with and without complications, as well as between patients with a history of major abdominal surgery and those without such a history.Results:Laparoscopic peritoneal dialysis catheter placement was aborted in 4 patients because of an inability to safely achieve sufficient access to the abdominal cavity through dissection; these patients were excluded from subsequent analysis. The mean follow-up period was 18.8 ± 12.9 months. Fifty-five patients had a history of major abdominal surgery compared with 61 without such a history. No significant difference was observed with respect to age, race, sex, or body mass index between groups. Notably, more adjunctive procedures were required in patients with previous abdominal surgery, including adhesiolysis (60.0% vs 4.9%, P < .0001) and hernia repair (12.7% vs 1.6%, P = .026). Postoperative catheter complications were not significantly different between patients with and patients without a history of abdominal surgery (29.1% vs 32.8%, P = .667). Both unassisted (56.8% vs 65.0%, P = .397) and overall (72.7% vs 76.7%, P = .647) 1-year catheter survival rates were similar between patients with and patients without previous surgery, and the overall 1-year survival rate improved to 83.9% on exclusion of patients who stopped peritoneal dialysis for nonsurgical reasons.Conclusions:Laparoscopic peritoneal dialysis catheter placement offers a chance to establish peritoneal dialysis access in patients traditionally viewed as noncandidates for this modality. Despite the potential risks incurred because of additional procedures at the time of catheter placement in these complicated cases, these patients can achieve good long-term peritoneal dialysis access with an aggressive surgical approach.

Greater omentum folding in the open surgical placement of peritoneal dialysis catheters: a randomized controlled study and systemic review.

Mechanical catheter dysfunction caused by omentum entrapment remains a major complication of peritoneal dialysis (PD) therapy. The purpose of this study was to determine the outcomes of omentum folding at the time of primary open catheter insertion. From March 2008 to December 2012, a total of 67 PD subjects were enrolled in the study and randomly assigned to receive either regular open insertion (ROI group, n = 33) or open insertion with omentum folding (OIOF group, n = 34). The primary outcome was defined as PD catheter tip migration with dysfunction. A systematic review was performed to analyze the outcomes of omentum management in PD catheter implantation, based on published data from 1990 to 2013. There was no statistical difference in baseline patient characteristics between the ROI and OIOF groups. Nine (27.3%) patients in the ROI group presented with catheter malposition in the late stage (>60 days) of the study, significantly more than in the OIOF group (two; 5.9%) (P = 0.049). Significant differences in catheter survival rate between the two groups were observed in the late stage (P = 0.030) and over the entire study period (P = 0.028). A higher incidence of irreversible catheter dysfunction was shown in the ROI group (15.2%), whereas none occurred in the OIOF group (P = 0.031). No statistical difference was determined in other catheter-related complications or patient survival rate. There were no statistical differences in peritoneal transport characteristics or dialysis adequacy between the two groups upon evaluation at 3, 6 and 12 months. Systemic review of current publications suggested that PD catheter placement with omentum management could lead to less irreversible catheter dysfunction and improved outcome of catheter survival. Our data suggest that omentum folding at the initial time of open catheter placement can significantly reduce the risk of catheter tip migration with dysfunction and improve the outcome of the PD technique.

Eficacia y seguridad del uso de solución de superoxidación en la prevención de infecciones relacionadas con diálisis

IntroductionIn Mexico, peritoneal dialysis (PD) is the most widely used dialysis method (60%). Infections of the peritoneum, exit site, and catheter tunnel are frequent, which impairs patients’ quality of life, increases investment costs, shortens the time dialysis can be used, and often requires a switch of dialysis modality. The aim of this study was to evaluate the efficacy and safety of a superoxidized solution (Microdacyn®) in reducing the frequency of dialysis-associated infections. Materials and methodsWe performed a controlled clinical trial with random allocation. Iodine solution was used in group I (GI) and superoxidized solution in group II (GII). We included incident patients undergoing PD without prior antibiotic therapy. We identified demographic variables, the time of occurrence of the first episode of infection, the clinical characteristics of the infectious process, the causative organisms, and clinical response. ResultsA total of 111 patients were included, 55% men and 45% women, with a mean age of 60.2 years (range: 18-90; SD 14.8), (P>.5). There were 57 patients in GI and 54 in GII. The primary causes of renal failure were diabetes mellitus, hypertension, chronic glomerulonephritis, and polycystic kidney disease (P>.5). None of the patients received antimicrobial prophylaxis at the time of peritoneal catheter placement. After 8 weeks of follow-up of intermittent PD, 14 infectious events (24.5%), 11 exit site infections (19.3%), and 3 tunnel infections (5.3%) were observed in GI, and 3 exit site infections (6%) were observed in GII (P<.05). ConclusionsTreatment with superoxidized solution had good efficacy and safety in the prevention of PD-related infections.

Increased Fluoroscopy Time for Central Venous Catheter Placement by Radiology Residents versus Staff Radiologists

To evaluate differences in interventional radiology procedural fluoroscopy time (FT) for radiology residents versus staff radiologists, using central venous catheter (CVC) placement as an index service. To minimize interservice and complexity variables, stand-alone temporary internal jugular CVC procedures were targeted for analysis. Reports and images from 1,067 temporary CVC services from 2 hospitals over 2 years were reviewed as part of a quality improvement initiative. Insertion site, catheter type (eg, smaller triple lumen versus larger hemodialysis), resident identifier, staff identifier, and documented FT were compiled and analyzed. Applying clinical (eg, concomitant venous angioplasty) and anatomic (eg, femoral access) exclusions, 537 cases with complete CVC procedure records were available for analysis. Radiology residents and staff radiologists were primary operators in 128 and 409 procedures, respectively. Distribution of resident procedures (82% right, 66% large lumen) was similar to that of staff (79% right, 63% large lumen). Mean FT of resident services was twice as long as that of staff services (1.24 minutes versus 0.63 minutes, P < .0001). Resident FT was independent of supervising staff radiologist. Increasing years of training for residents did not significantly reduce FT. When CVCs are placed by radiology residents, FT is double that for identical procedures performed by staff radiologists. Similar discrepancies likely exist for other interventional radiologic procedures. Residency training programs should initiate measures to monitor and manage fluoroscopy during interventional procedures to minimize radiation dose to patients, trainees, and other staff.

4:10 PM Abstract No. 115 - Hematomas - to drain or not to drain, the interventionalist's dilemma

Purpose Determine outcomes associated with the percutaneous drainage of hematomas. Materials and Methods A retrospective analysis was performed of the last 50 drainages performed at this institution that had the appearance of bland blood products at drainage. 26 males and 24 females were included in the study with an age range of 14-90 and an average catheter placement time of 35 days. Evaluation of length of catheter drainage, need for reintervention, and outcomes were assessed. Results Of the 50 drainages in which fluid had the appearance of bland blood products expressed at drainage in the period between 8/2010- 2/2012, 41 had catheters placed. 9 were drained without catheter placement. Of the 9 in which a catheter was not placed, 0 had a positive culture. Of the 41 in which catheters were placed, 31 had positive cultures at analysis. 10 had negative cultures. Of the nine in which catheter placement was not performed 3 had minimal fluid aspirated, in 2 the clinician specifically requested no drain be placed, 1 was a liver lesion in which it was elected not to place a drain, and 3 were tiny collections in which the clinical services were requesting aspiration for culture only. All 50 were successfully drained by SIR criteria for diagnosis, with 46 patients resolving the clinical episode that precipitated drainage. Of these patients there were no serious complications associated with catheter placement, although 3 ultimately developed fistulas to bowel, pancreas, and biliary system, and the one death prior to catheter removal was related to multiorgan failure in a liver transplant patient perioperatively. Conclusion Hematoma drainage attempt may be warranted in most cases, given the very high association of bland appearing hematoma with positive culture (62%), and the frequency in which drainage was possible despite the collections appearing to contain only blood products(86%). In cases in which minimal fluid is returned from a collection that appears large enough to drain it may be appropriate to avoid catheter placement, as these collections may have a lower likelihood of infection.

The Learning Curve Associated with the Epidural Technique Using the Episure™ AutoDetect™ Versus Conventional Glass Syringe

The Episure™ AutoDetect™ (spring-loaded) syringe has been observed to successfully identify the epidural space in 2 pilot studies. In this study we evaluated the impact of the spring-loaded syringe on the establishment of successful epidural labor analgesia (primary outcome), elapsed time for catheter placement, and learning curve (cumulative summary analysis, i.e., Cusum) of experienced anesthesiologists. Fourteen attending and fellow anesthesiologists were randomized to perform 50 consecutive epidural technique attempts using a spring-loaded or conventional glass syringe. Ten participants completed an additional 50 attempts with the alternate syringe in a crossover design. A total of 1200 epidural placement attempts were performed. Use of the spring-loaded syringe was associated with a nonsignificant difference of estimated success rate in obtaining analgesia success (absolute difference of 1.0% 95% confidence interval, CI: -8.9% to 10.8%), shorter elapsed mean time to epidural catheter placement (ratio of 0.92 95% CI, 0.89-0.96); P = 0.003) and similar Cusum curves when compared with a conventional glass syringe. Analgesia success was more common with attending versus fellow anesthesiologists (absolute difference of 34.6% 95% CI, 14.9% to 54.3%; P < 0.001), and when the initial preferred technique was loss-of-resistance to continuous saline versus intermittent air (absolute difference of 33.8% 95% CI, 12.6% to 55.0%; P < 0.001). Shorter elapsed mean times were also observed in the group exposed to the spring-loaded syringe first (ratio of 0.65 95% CI, 0.62-0.67; P = 0.02). When used by experienced obstetric anesthesiologists, the spring-loaded syringe was associated with a similar overall rate for establishing successful epidural labor analgesia, a shorter elapsed time to epidural catheter insertion, particularly when the anesthesiologist was randomized to use the novel syringe first, and a similar Cusum curve when compared with a conventional glass syringe. Attending versus fellow anesthesiologists and an initial technique preference for loss-of-resistance to continuous saline were associated with greater analgesia success with the novel syringe.

Microbial biofilm formation and catheter-associated bacteriuria in patients with suprapubic catheterisation

Catheter-associated bacteriuria (CAB) with transurethral catheters is almost inevitable. Suprapubic catheters (SPCs) are widely considered to decrease the risk of CAB. However, SPCs are implants similarly prone to microbial biofilm formation. The spectrum of colonising pathogens has not been investigated. The aim of this prospective study was: (1) to assess the diversity of microbial suprapubic catheter colonisation (MSPCC), (2) to identify risk factors and (3) to investigate its association with CAB and catheter-associated urinary tract infection (CA-UTI). A total of 218 SPCs from 112 patients were studied. Urine specimens were obtained after device replacement or removal. Sonication was performed to dislodge adherent microorganisms. Data of patient sex, age, indwelling time, and underlying disease were recorded. Sonicate-fluid culture (SFC) detected MSPCC in 95 %. Increasing indwelling time correlated with MSPCC (p < 0.05). Negative SFC was more frequent when antibiotic prophylaxis was applied at time of catheter placement (15 vs. 2 %, p < 0.05). Most commonly isolated were Enterobacteriaceae (45.8 %), followed by Enterococcus spp. (25.7 %) and Pseudomonas aeruginosa (10.3 %). CAB and CA-UTI were observed in 95 and 11 %, respectively. This study provides the first analysis of MSPCC. Indwelling time increases, whereas antibiotic prophylaxis decreases the risk of MSPCC. The spectrum of pathogens is comparable to the one obtained from urethral catheter biofilms. Urine specimens could not demonstrate the microbial diversity of MSPCC. SPCs are not preferable to urethral catheters to reduce CAB. Whether the risk of CA-UTI could be minimised by SPCs remains to be clarified.

A Randomized and Observer Blinded Comparison of Continuous Femoral Block and Fascia Iliaca Compartment Block in Hip Replacement Surgery

Background: Techniques, analgesic effects and functional outcome of continuous femoral nerve and fascia iliaca compartment blocks were compared in patients undergoing hip replacement surgery. Methods: 80 patients were enroled in this randomized and observer-blinded study. 40 patients received a femoral nerve catheter with a stimulating catheter (FEM group) and 40 patients a fascia iliaca compartment catheter (FIC group). Before surgery, the catheters were placed. 50 mL prilocaine 1% was administered and a continuous infusion of ropivacaine 0.2% was maintained for 24 hours. Postoperative pain management with non-steroidal antiinflammatory agents was standardized during the first 24 hours. No bolus application of a local anesthetic was allowed during this period. Intravenous opioide PCA with piritramide (comparable with morphin) was provided for 24 hours, and the patients were instructed to titrate their pain below a level of visual analogue scale of 3. We evaluated the catheter placement time, the time until complete sensory and motor block, the analgesic efficacy and functional outcome with WOMAC Index, Harris Hip Score, Lequesne Score and SF 36 questionnaire. Results: Catheter placement was faster in the FIC group (3 minutes vs. 5 minutes in mean; p <0.05). Time until sensory and motor blockade was faster in the FEM group except for the lateral part of the thigh. No significant difference was noted between the groups regarding median VAS pain values and consumption of piritramide within 24 hours. No differences in functional outcome after 12 and 90 days of surgery could be observed. Conclusions: The fascia iliaca compartment catheter can be placed more quickly than the femoral nerve catheter with the stimulating catheter technique, but onset time of sensory and motor blockade is longer when performing the fascia iliaca compartment technique. Both techniques have equivalent postoperative analgesic efficacy in hip replacement surgery without any difference in functional outcome. In case of contraindications for a classic femoral nerve block, the fascia iliaca compartment block is an equivalent procedure.

Techniques for Hyaluronidase-Facilitated Subcutaneous Fluid Administration With Recombinant Human Hyaluronidase

Recombinant human hyaluronidase facilitates subcutaneous (SC) fluid delivery, but little is known about how various access sets influence ease of administration, technical challenges (TCs), or adverse events. This randomized, open-label, parallel-group trial was performed to assess the impact of catheter size (20- and 24-gauge short peripheral intravenous catheter, 27-gauge SC button), catheter material (Teflon, polyurethane), and securement method (transparent semipermeable membrane dressing [TSM], double chevron with cloth or plastic tape) on hyaluronidase-facilitated SC fluid delivery. Healthy volunteers (N = 100) were randomized to 1 of 9 access groups using a factorial design. To minimize variability, treatment was performed at a single center and standardized to 150 units of SC recombinant human hyaluronidase (HYLENEX, Baxter Healthcare Corporation) followed by 1000 mL of lactated Ringer's solution. The first attempt at needle insertion succeeded in 98% of subjects; the median time for first catheter placement was less than 1 minute. The median infusion time was 6.8 hours. Overall, the incidence of TCs observed (catheter kinking, dislodgment, or pullout or infusion pump alarm) was low and comparable across groups (16.7%-27.3%); however, catheter kinking, dislodgment, and pullout occurred only in groups using double- chevron securement. Infusion-site reactions (pain, 20%-75%; erythema, 17%-36%; swelling, 0%-33%) were the most common adverse events. Pain was less frequent in groups using the 27-gauge SC button (27%) or the 24-gauge catheter (20%-36%) than with the 20-gauge catheter (50%-75%). Hyaluronidase-facilitated SC fluid administration with recombinant human hyaluronidase was generally well tolerated and successfully implemented using a range of access sets. Technical challenges were not common but were further minimized with TSM securement. Infusion-site pain was mostly mild and least common with 24-gauge or smaller catheter/needles.

Ongoing Consideration of Cavity Evaluation Devices in the Treatment of Breast Cancer

The growing popularity of brachytherapy has greatly increased the use of single-entry balloon catheter devices for delivery of accelerated partial breast radiotherapy (APBI). To facilitate delayed, postoperative, percutaneous insertion of single-entry brachytherapy catheters, many surgeons elect to place temporary, expandable cavity evaluation devices (CED) at the time of lumpectomy to preserve the surgical cavity and maintain a tract between the skin and surgical cavity. At the time of brachytherapy catheter placement, the CED may be deflated, withdrawn from the cavity, and easily replaced by a single-entry brachytherapy catheter inserted through the very same tract. In their article, ‘‘Spacer Balloons prior to Partial Breast Irradiation: Helpful or Hurtful?’’, Drs. Kuske and Zannis provide an excellent summary of the potential limitations and challenges associated with CED usage. While they have raised several important concerns, the authors’ emphasis on the potential negative aspects of CED placement misses the opportunity to provide sufficient guidance on how and when they may be properly used. Among the important concerns raised by the authors is the tendency of some surgeons to obtain multidisciplinary consultation only after CED placement. Preoperative discussion of the patient’s treatment options in a multidisciplinary setting or referring the patient to a radiation oncologist prior to surgery will provide the best opportunity for the patient and her oncologists to identify and fully discuss the options of lumpectomy, APBI, CED usage, and the implications of unsuitable pathology. This process not only helps to identify patients who are suboptimal candidates for APBI, but also allows coordination of surgery, catheter exchange, and radiation therapy planning to avoid the significant delays in the initiation of APBI that the authors identify as being contributory to devicerelated infections. Preoperative consultation also gives the patient the opportunity to discuss their potential participation in clinical trials that might be impacted by CED placement. Another compelling issue raised by the authors is the higher incidence of wound infection associated with intraoperative placement of a brachytherapy catheter (the open-cavity technique) compared with postoperative, percutaneous brachytherapy catheter placement (the closedcavity technique). However, the association between CED placement and infection is far from clear. In referencing the 2-year outcome data of the MammoSite Registry, the authors acknowledge that CED usage was not specifically addressed in the publication. Although it is reasonable for the authors to infer that intraoperative placement of a CED is analogous to open-cavity placement of a brachytherapy catheter in terms of its risk of infection, the results of the MammoSite Registry are confounded by the lack of clear guidelines regarding the use of antibiotics. In fact, only 71% of MammoSite Registry participants received antibiotics. Perhaps patients who had catheters placed intraoperatively were less likely to be prescribed oral antibiotics because they were routinely given a single dose of intravenous antibiotics preoperatively. Alternatively, it could be that patients who had catheters placed postoperatively were more likely to be prescribed postprocedural oral antibiotics because they did not receive the benefit of preprocedural intravenous antibiotics? The MammoSite Registry update does not elucidate these factors. Furthermore, since there is a finite risk (1–4%) of surgical-site infection after breast-conserving surgery, to what degree does the higher incidence of infection after the open-cavity technique reflect the combined result of postlumpectomy infection and catheter-related infection. Interestingly, the Society of Surgical Oncology 2011